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The fundamental principles of the Mitanin Programme : and The Challenge of Large Scale Government le


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Title: The fundamental principles of the Mitanin Programme : and The Challenge of Large Scale Government le

The fundamental principles of the Mitanin
Programme and The Challenge of Large Scale
Government led Community Health Worker Programmes
Objectives of the Mitanin Programme
  • Improve awareness of health and health
  • Improve utilisation of existing health care
  • Provide a measure of immediate relief to health
  • Organise community ,especially women and weaker
    sections on health care issues
  • Sensitise panchayats and build capabilities

Operational Objectives
  • 1. Select a Mitanin in every hamlet of the state-
    60,000 in all.
  • 2. Train the Mitanin over 18 months- 20 days of
    camp based training and 30 days of on the job
    training at the village. Induction training. Then
    12 days of camp based and 30 days of on the job
    every year.
  • 3.Provide support to Mitanin in her in her work
    and closely coordinate with ANM and AWW for
    maximal effectiveness.

We know that CHWs can make a major impact on
child survival
The case of Jamkhed, Maharashtra
  • Prompt first contact life saving visits-
    diarrhoea, ARI fever
  • Home based newborn care,
  • Facilitate closure of service gaps (esp.
    immunisation ANC.)
  • Referrals- sick child and neonate.
  • Child nutrition counseling.
  • Key messages/practices that every family will

Earlier Programmes
  • Community Health Worker- Jamkhed, SEWA Rural,
    Mandwa(FRCH), RUHSA,(Vellore), SEARCH(
  • Community Health Worker 1977
  • Village Health Guide- 1984
  • Link Worker Depot holder
  • JanSwasthya Rakshak- 1997

What are the Compulsions for a Community health
  • 4692 subcenters, 26,000 villages and 54,000
    hamlets- For improved child survival every
    newborn, every diarrhoea, every ARI, every case
    with fever- must be seen on Day One. Just not
    possible for a govt cadre
  • Govt programmes do not succeed without Community
    Support- and this requires investment in
    systematic community processes
  • Health education requires someone from within
    the community who knows the local dialect, base
    line knowledge, idiom and perceptions,

The spirit of a CHW programme
  • Health is not a commodity that a benevolent state
    can force a reluctant population to consume!!!!
  • Health is a set of processes that occur at the
    level of the family and the community in the
    context of their daily working and living
  • Peoples Health in Peoples Hands
  • Hamaar swathya hamaar haath

Spirit of the programme
  • Free health care services is not an act of
    compassion for the poor.
  • Health care service is an entitlement a basic
    human right!!
  • Swasthya Hamar Adhikar Havai
  • .

Earlier Programmes and Mitanin Programme-
  • Earlier Programmes
  • Largely Men
  • Community Health workers esp in JSRs and CHWs
  • Mitanin Programme
  • Only Women
  • Perception of Health as a value in itself.
  • More concern on health in family and in society
  • More focus on health education
  • Less interest in becoming a quack

The Selection Process
  • Earlier Programmes
  • Usually by health staff
  • Or by Panchayats- as representing the
    community-but panchayats often represent vested
    interests health staff seek docile help not
  • Mitanin Programmes
  • By the general body of the village
  • Subject to approval of the village
  • After both of the above have been sensitized by
    meetings conducted by trained facilitator and
    mobilized and motivated by specific processes
    like kalajatha.

The level of operation/coverage
  • Usually one for village
  • One for each hamlet
  • Better coverage
  • Effectively handles issues of marginalisation of
    some communities
  • Compatible with voluntarism..

Curative centeredness
  • Earlier Programmes
  • because without catering to felt need one
    cannot moblise for prevention
  • In NGO CHW programmes effective curative care
    demonstrated but little preventive or promotive
    indicators studied
  • In govt programmes eg JSR only poor quality
    curative care remainedNo specific plans for
    preventive /promotive work
  • Mitanin Programme
  • curative care supplementary- not central
  • Introduced in training only after all other
    preventive and promotive aspects of the programme
    are trained and deployed and assessed
  • Effective plans for preventive and promotive care
    and indicators chosen and used( I.M.C.I health
    education, local planning etc )

Tendency to quackery
  • Earlier govt. programmes
  • Drugs had to be prescribed
  • No referral systems
  • User fees and prescribed drugs actively
    encouraged in the JSR and similar programmes.
  • Mitanin Programme
  • Drugs provided by the government
  • Active referral system
  • Resisting harmful curative care made part of the

The honorarium issue
  • Earlier programmes
  • Honorarium drives and ensures participation- in
    training( for JSR) and in work ( for CHW).
  • Mitanin Programme
  • No honorariums
  • Performance based incentives used.
  • Motivation and support has to sustain

The arguments for and against honorarium
  • For
  • needs compensation for loss of livelihood.
  • When everyone else is paid why not this
    volunteer- it is discriminatory and unfair.
  • We cannot secure participation without it
  • We cannot sustain participation without it and it
    is difficult to retrain every time there is a
    drop out.
  • Against
  • Only that much work given as can be done without
    loss of livelihood
  • Should be seen as representative of community,
    -paying her is inadequate for livelihood but
    makes her lowest paid employee of department
  • Safeguards selection process from pressures and
    vested interests.

But we also know that too often such models have
  • Why is it that
  • Small Scale CHW Programmes with NGO leadership
  • while Large Scale Programmes which are
    Government organised Do poorly

So what is lost with scale..
  • 1 Motivated Leadership The Antia Factor..
  • Its alright one can do it in Jamkhed or in
    Mandwa- but how can one get an Arole or an Antia
    or an Abhay Bang in every place.
  • Requirement one Antia per every 30 villages or
    at least every 150 villages. Chhattisgarh would
    require approximately 2000 Antias
  • The commitment and the costs

And what else goes
  • 2. Quality of Training the problem of
    transmission loss in the training cascade..
  • 3. Quality of Trouble-shooting On the Job
  • 4. Quality of MonitoringIdentifying the weak
    areas and responding to them.

And further lost with scales are
  • Quality of Referral Support in the CHW programme
    ( reform in institutional structures that play
    higher order roles needed to complement and later
    sustain the programme).
  • A tradition of working with local community that
    provides links.
  • An ability to persist, learn and correct..
  • Evaluation manage able Sample Size and
    representative qualitative inputs.

Referral Support the Mitanin Programme
  • All small NGO programmes had a very good base
    hospital with a medical team.
  • But when we scale up the PHC and CHC have to play
    this role.
  • Not a problem, not just an opportunity but part
    of the purpose itself.
  • Mitanin Programme becomes an idiom of health
    sector reform and some of this may outlast the
    Mitanin itself!!!!

Mitanin as Health Sector Reform..
  • The creation of the SHRC.
  • The linkage of funds flow of Mitanin programme to
    developments in all parallel areas of public
    health system strengthening.( over 14 specific
    dimensions )
  • The 39 increase in state budget- the over 50
    increase in total public health expenditure.( but
    now reached 4 of outlay)
  • The creation of 874 HSCs, 200 PHCs and 16 CHCs to
    close all institutional gaps, the move to 2
    doctor PHCs, the 4 specialist , 7 doctor CHC, the
    pressure to make FRUs functional, the opening up
    of ICDS centers..
  • Major programme of CHC PHC improvement
  • Long way to go.. But the Mitanin is the
    flagship.. Bringing health one step further on
    the political agenda. In myriad number of ways..
    Eg increasing immunisation on hearing the
    announcement / effect on the visiting CMs and
    VIPs.the flow of aid etc.

Securing community level processes in the Mitanin
  • In absence of long involvement with local
    community( and even if..) who speaks for the
    community?? In NGO programmes we have a
    discerning listener Whose gaze defines what is
  • But when the dt administration gives the appeal..
    Either the panchayat elite appropriate the voice,
    or the department functionary does. Who informs
    the community, who enthuses the individuals? Who
    amplifies the voice of the weak?
  • Hence the need for the trained facilitator- the
    prerak- and for a defined process of social
    mobilisation- songs and plays taking through the
    spirit of the programme.
  • But who selects the prerak? Need to define a set
    of processes and have a support structure to
    guide this
  • Principle An intermediary force is a must but
    such a force brings with it a new set of problems

Programme duration as a variable
  • Need to allow for programme structures and
    personnel to evolve.
  • Need to allow for people to come in and leave and
    others to come in
  • And after a structure stabilises one needs to do
    and re-do many parts of the programme..
  • And all this needs time and persistence with the
    programme and learning curves..
  • This happens in small programmes too but
    external documentation often misses it as
    compared to first person accounts.. But it needs
    to be built in.
  • Mitanin Programme went two moults and is in the

Pace of the Programme as a variable..
  • Need to sustain pace of the programme for both
    the effect of social mobilisation and to keep it
    on the political agenda.
  • Enough time to allow for a minimum set of well
    defined processes and enough to allow for
    evolution of structures.. And constant
  • But longer duration by itself is not a virtue
    And one needs constant innovation

Staggering the Programmes- 3 critical steps
  • Pilot phase builds the tools -builds the state
    leadership- tends to do poorly. 14 blocks-
  • First phase- builds the district teams, gets the
    systems in place- 66 blocks
  • Second phase-- reaches out to full coverage --66
  • Subsequent phases- re do various aspects, bring
    in corrections , innovations etc.-

Addressing Transmission losses in training
  • Three Key Steps
  • High voltage Capable full time top of the
    pyramid key resource persons- full time
    hand-picked and personally trained team.
  • Good conductors Insistence on systematic use of
    training material.
  • Step up transformers Use of training evaluation
    (and on the job back up).

Emergence of a training cadre..
  • Whether and how --Related to existing human
    resource availability.
  • Do we have surplus ANMseven outside the
    government employment( like in andhra pradesh)
  • Can the existing ANM play this role?
  • Do NGOs have the required persons or expertise?
  • This cadre needed in monitoring and provision of
    on the job training.
  • But would have low/zero clinical skills.
  • All experience would eventually be learnt from
    the field and limited by the quality of
    supervision possible.
  • Needs strategy of trainer recruitment and
    replacement and evolution of this workforce.
  • Mitanin has now over 3000 trainers and 300 dt
    resource persons and 25 state trainers

Strategy of Monitoring
  • The small NGO programme relies on the review
  • But in the large programme .
  • Need to put in place a set of defined processes-
    the cluster meeting, the block trainers review,
    the district coordination meeting, the state
    nodal officers review, the state field
    coordinators review.
  • Need to put in place a large workforce to do
    this- the trainers cadre.. The nodal officer
    heirarchy.. The field coordinator.
  • Need to carefully make a choice of Monitoring

Monthly Monitoring Indicators
  • New born visit and change in six practices
  • Over 10 to 20 first day requests for curative
  • Visit in last trimester of pregnancy and the plan
    for child-birth.
  • Attendance at the immunisation day.( convergence
    and service facilitation)
  • Knowing the children at risk and counselling.
  • DOTS provider role
  • The hamlet level meeting.
  • Observable, Measurable, verifiable from parallel
    sources, aggregatable.

  • Getting sample sizes involves costs and research
  • Needs clear definition of outcomes and its
  • Need care in relating processes to outcomes.
  • Qualitative studies needed to catch enormous
  • Qualitative studies needs training in qualitative
    methodology, the anthropologists or sociologists
    skills.. and this is difficult to obtain and even
    more difficult to standardize.
  • Internal evaluation with in built externality
    with key processes under qualitative study offers
    a way forward.
  • To be wary of experience- need to have grounding
    in methodology.

How to get an Antia everywhere
  • The Gaussian curve
  • All biological and most social systems display a
    bell shaped normal distribution. So too should
    motivation..5 to 25 in any group of a
    reasonable size- will potentially have a sense of
    motivation- to work with self lessness. Whether
    it be NGOs or government officers or BEEs
  • And one needs to have a way of searching for and
    finding this 5. How to sift through and how to
    adsorb onto the system..

The Power Principle
  • Needs to define the determinants of the x axis
    location of the system- where motivation is on
    the y- axis..
  • There are relationships of power embedded in
  • Knowledge.
  • Institutional structures
  • Mind-sets/attitudes
  • Programme designs-
  • Not just the key decision but every single
    detail is power-laden!!
  • Relationship to these define the x- axis of
  • And the leadership needs to be able to question
    existing relationships in all of these domains.
    And that indeed defines leadership
  • Need to have the catalyst in place who can
    constantly work on redefining these
    determinantsat every level.

Uneven Pace of Progress..
  • Categorised into 4 groups
  • A-(gt75) 16 blocks
  • B- (55-75)47 blocks
  • C- (35- 55)63 blocks
  • D- ( lt35)20 blocks
  • of Mitanins functional as averaged for these 6

Trends In Rural Total IMRIndia, MP
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The recipe.
  • Get a mix of state and civil society at every
    level. never one or the other alone.. Carefully
    define the institutional mechanisms for this
  • Let structures/ key persons evolve with
    considerable flexibility and innovation..
  • Put in a strong dose of social mobilisation-
    questioning existing values eg patriarchy, caste
  • Have a catalyst- the facilitator- in place to
    absorb the right persons and highlight , support
    and build capabilities in- to mentor.
  • Negotiate, negotiate, negotiate-

  • Thank you